Draft Standards

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Standard 01.HCS.PM.1:
Leadership roles are clearly defined.

Performance Requirements for 01.HCS.PM.1

• PM.1 -
1. The program defines the accountability of its leaders.
2. The program defines its scope of services.
3. The program provides its leaders opportunities for sharing of best practices with leaders of other similar programs.
4. The leaders promote an atmosphere for learning and redesign.
5. Leaders and staff relationships support a collaborative and trusting environment.
6. Leaders provide for the integration of the service with other services and providers.
7. The leaders provide for resources to meet the scope of services provided.
8. The leaders establish or provide staff access to ethics consultation or a process to address and resolve ethical conflicts.
9. Leaders facilitate effective communication throughout the program.
10. The program complies with applicable law and regulation.

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Standard 02.HCS.PM.2:
The program has a process to address complaints.

Performance Requirements for 02.HCS.PM.2

• PM.2 -
1. The program gives a written description of the complaint process to patients.
2. Staff are aware of the complaint process.
3. Leaders review and resolve complaints from patients and staff.

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Standard 03.HCS.PM.3:
Leaders are responsible for selecting, orienting, continuously educating, retaining, and providing incentives for staff.

Performance Requirements for 03.HCS.PM.3

• PM.3 -
1. Staff have education, experience, training, and/or certification consistent with the program’s mission and goals.
2. Leaders evaluate the qualifications, training, and experience of individuals who are considered for membership on the program team, or delegate this responsibility. (See also standard PM.4)
3. Orientation for the program team members includes information and necessary training pertaining to program responsibilities.
4. The program identifies and responds to program team members’ specific learning needs.
5. Ongoing education, including in-services, training, and other activities, maintains and improves practitioners’ competence.
6. (Not applicable to Core – Palliative Care specific)
7. Leaders establish policies that address the provision of emotional and psychological support for staff.

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Standard 04.HCS.PM.4:
The program has an interdisciplinary team which includes people with expertise in and/or knowledge about the program’s care, treatment, and services.

Performance Requirements for 04.HCS.PM.4

• PM.4 -
1. The program defines in writing the composition of the program team.
2. The program defines in writing the team members’ responsibilities.
3. Based on the services it provides, the program team includes, or has access to, individuals experienced in: medicine; nursing; nutrition; pediatrics; child life services; pharmacology; rehabilitative services; psychology; and social work.
4. The program team consistently uses the services cited in Standard PM.4, element of performance 3.
5. Practitioners maintain a current professional license or certification, in accordance with law and regulation.
6. Practitioner competence to perform job responsibilities is assessed, demonstrated, and maintained within program-defined time frames.

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Standard 05.HCS.PM.5:
The program uses practices originating from evidence-based national guidelines or expert consensus to deliver or facilitate the delivery of clinical care, treatment, and services.

Performance Requirements for 05.HCS.PM.5

• PM.5 -
1. The program develops policies and procedures to support the delivery of care, treatment, and services.
2. The program reviews clinical practices for appropriateness on an ongoing basis.
3. The program has a process to approve the use of clinical practices.
4. Practitioners are educated about clinical practices.

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Standard 06.HCS.PM.6:
The program identifies and minimizes risks to patients.

Performance Requirements for 06.HCS.PM.6

• PM.6 -
1. The program identifies safety risks associated with the environment of care. Specific environmental elements to consider include: equipment usage, fire safety, communication services, utilities services, preventing and controlling infection, and patient security.
2. The program plans strategies to minimize the risk of disruption of care.
3. The program takes action to minimize safety risks in the physical environment.
4. Staff know their roles and responsibilities relative to safety.
5. The program evaluates the effectiveness of its activities for creating and maintaining a safe environment of care.

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Standard 07.HCS.PC.1:
Patients with comparable needs receive the same standard of care, treatment, and services.

Performance Requirements for 07.HCS.PC.1

• PC.1 -
1. (Not applicable to Core – Palliative Care specific)
2. The program informs patients and families how to access care, treatment, and services during business hours.
3. The program informs patients and families how to contact staff in the case of an emergent situation during or after business hours.
4. The program informs patients and families about their rights and responsibilities while receiving care, treatment, or services.
5. The program assists patients to maximize the use of community resources available to meet their health care needs.
6. The program informs patients of their responsibility to provide information that is important to care, treatment, and services.
7. The patient has a right to decline participation in the program or elements of the program.
8. Services provided through contractual arrangement are evaluated to ascertain whether the scope and level of care, treatment, and services are consistently provided.

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Standard 08.HCS.PC.2:
The program involves patients and families in decision-making.

Performance Requirements for 08.HCS.PC.2

• PC.2 -
1. Patients receive information about the staff responsible for the delivery of care, treatment, or services.
2. The program assesses how patients want to receive information, including the type and extent of information.
3. The patient’s wishes about how he or she wants to receive information is communicated to practitioners across the care continuum.
4. The program provides patients information about their rights and responsibilities while receiving care, treatment, or services.
5. The program educates patients and families on disease processes, prognosis, and the benefits and burdens of potential interventions so that they are able to make informed decisions about their care.
6. The program involves patients in decisions about their clinical care.
7. Patients and practitioners mutually agree upon goals of care.
8. The program promotes advance care planning.
9. (Not applicable to Core – Palliative Care specific)

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Standard 09.HCS.PC.3:
The program tailors processes to meet the patient’s lifestyles, needs, and values.

Performance Requirements for 09.HCS.PC.3

• PC.3 -
1. (Not applicable to Core – Palliative Care specific)
2. The documented plan of care is developed based on the patient’s assessed needs, strengths, limitations, goals, and values.
3. The plan of care is based on a comprehensive interdisciplinary assessment of the patient’s values, preferences, goals, and needs. (see also Standard PM.4 EP 2)
4. The program informs the patient about potential consequences of care, treatment, and services, including consequences if the patient chooses not to follow recommendations.
5. The program delivers care, treatment, and services according to the individualized plan of care.
6. The program provides care, treatment, and services in a manner that meet the patient’s cultural and linguistic needs.
7. The program communicates the plan of care to professionals involved in the patient’s care. (see also Standard IM.1 EP 3)
8. The program informs the patient about the outcomes of care, treatment, and services that have been provided, including unanticipated outcomes and sentinel events. (see also Standard PC.2 EP 5 and Standard PI.4 EP 2)
9. The program evaluates and revises the plan of care to meet the patient’s ongoing needs and documents the revisions in the patient’s medical record.

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Standard 10.HCS.PC.4:
The program assesses and reassesses the patient’s needs.

Performance Requirements for 10.HCS.PC.4

• PC.4 -
1. Initial assessments, as defined by the program, are performed and documented in the medical record. (see also Standard IM.3)
2. The program assesses cultural, spiritual, or religious beliefs and practices important to the patient that influence care, treatment, or services.
3. (Not applicable to Core – Palliative Care specific)
4. (Not applicable to Core – Palliative Care specific)
5. The program completes the assessment(s) within its defined time frame.
6. The program reassesses the patient as defined by the program and whenever there is a change in the patient’s condition or a change in the patient’s preferences. The reassessment is documented in the medical record.
7. (Not applicable to Core – Palliative Care specific)
8. (Not applicable to Core – Palliative Care specific)

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Standard 11.HCS.PC.5:
The program provides care, treatment, and services according to the plan of care.

Performance Requirements for 11.HCS.PC.5

• PC.5 -
1. The program has a process to provide the patient with or refer the patient for emergency/urgent care.
2. Services are provided in an interdisciplinary, collaborative manner.
3. The patient’s comfort and dignity are priorities.
4. The patient’s physical symptoms are managed effectively according to the patient’s plan of care.
5. (Not applicable to Core – Palliative Care specific)
6. The patient is monitored for the effects of medications.
7. (Not applicable to Core – Palliative Care specific)
8. (Not applicable to Core – Palliative Care specific)
9. (Not applicable to Core – Palliative Care specific)
10. The program provides education, training, and support to the patient, addressing the patient’s need for safe and suitable care.
11. The program addresses the patient’s need for education about lifestyle changes that support self-management regimens.
12. The program addresses the education needs of the patient regarding disease prevention.
13. (Not applicable to Core – Palliative Care specific)
14. (Not applicable to Core – Palliative Care specific)
15. (Not applicable to Core – Palliative Care specific)

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Standard 12.HCS.PC.6:
Care is coordinated through communication.

Performance Requirements for 12.HCS.PC.6

• PC.6 -
1. Patients with co-occurring conditions are managed. Note: If the patient’s co-occurring condition(s) is managed by practitioner(s) or setting(s) outside of the program, the information necessary for its management is communicated to practitioner(s) and setting(s) across the continuum of care.
2. The program conducts regular patient care conferences with members of the interdisciplinary team to discuss goals of care, disease prognosis, and advance care planning, and to offer support.
3. The program assists the patient in collecting, organizing, and communicating important health information. (see also Standard IM.1 EP 3)
4. A process addresses the needs for continuing services after discharge, transfer, or service completion.
5. At the time a patient is transferred to a different care setting, information about the patient’s goals, preferences, and values and the patient’s clinical condition are communicated to the providers in the new setting.

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Standard 13.HCS.IM.1:
Information management processes meet internal and external information needs.

Performance Requirements for 13.HCS.IM.1

• IM.1 -
1. Staff have access to patient and family information when needed.
2. The program gathers information directly from the patient and practitioners or health care organizations.
3. The program shares information directly with the patient and other practitioners or health care organizations.
4. The program respects the patient’s right to and need for effective communication.
5. The information management processes provides information within a time frame that makes it available for use in decision making
6. The program assists in arranging for knowledge-based information resources and references required by the patient and staff.

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Standard 14.HCS.IM.2:
The organization maintains and protects the security and integrity of health information.

Performance Requirements for 14.HCS.IM.2

• IM.2 -
1. The program has a written policy to address privacy, confidentiality, and security of information. Note: Health information is protected under the Health Information Portability Accountability Act (HIPAA).
2. The program defines access limitations to information for individuals and/or positions.
3. The program safeguards records and information against loss, destruction, tampering, and unauthorized access or use.
4. The program defines the process to follow when confidentiality or security of information is breached.
5. The program implements its privacy, confidentiality, and security of information policy.
6. The program retrieves data without compromising security and confidentiality.
7. The program communicates its privacy, confidentiality, and security of information policy to staff and the patient.
8. The program informs staff and patients about its uses and disclosure of protected health information and obtains consent for release of information when required.
9. Patients are made aware of how data and information related to them will be used by the program.

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Standard 15.HCS.IM.3:
The program maintains complete and accurate medical records.

Performance Requirements for 15.HCS.IM.3

• IM.3 -
1. The medical record contains sufficient information to identify the patient.
2. The program documents in the patient’s medical record information pertaining to the course and results of care, treatment, and services.
3. The program documents in the patient’s medical record enough information about the patient to promote continuity of care among providers, both internal and external to the program.
4. The program reviews its medical records for completeness and accuracy within its defined time frames.
5. The program retains records, data, and information in accordance with law and regulation.

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Standard 16.HCS.IM.4:
Continuity of information is maintained.

Performance Requirements for 16.HCS.IM.4

• IM.4 -
1. The program has a service continuity plan, which includes disaster recovery, for information systems.
2. The program’s service continuity plan includes identification of the most critical information for care, treatment, and services.
3. The program’s service continuity plan includes an assessment of the potential impact to the program and patients of a severe interruption of information systems.

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Standard 17.HCS.PI.1:
The program plans an organized, comprehensive approach to performance improvement.

Performance Requirements for 17.HCS.PI.1

• PI.1 -
1. The program has a performance improvement plan.
2. The leaders, staff, and patient(s) collaborate to evaluate the provision of services.
3. The program sets performance improvement priorities and identifies how the program adjusts priorities in response to unusual or urgent events.
4. The program plans process and performance improvement activities to encompass multiple disciplines and/or settings.
5. The program implements its performance improvement plan.
6. The program’s performance improvement activities are made publicly available.
7. The program improves and sustains performance based on the analysis of its data.

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Standard 18.HCS.PI.2:
The program collects data to monitor its performance.

Performance Requirements for 18.HCS.PI.2

• PI.2 -
1. The program collects the data it needs to improve processes and outcomes.
2. The program uses data sets, definitions, codes, classifications, and terminology consistently within the care setting.
3. Data collection is timely, accurate, complete, and relevant to the program.
4. The program selects valid, reliable performance measures based on evidence-based national guidelines or, in the absence of such guidelines, expert consensus, and in the absence of both, a review of the health care literature.
5. The program collects data related to processes and outcomes at the level of the individual patient.
6. The program collects input related to patient satisfaction about program specific characteristics.
7. The program monitors the quality of data collected.

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Standard 19.HCS.PI.3:
The program analyzes its data.

Performance Requirements for 19.HCS.PI.3

• PI.3 -
1. The program analyzes current performance.
2. The program uses statistical tool and techniques to analyze data.
3. The program identifies and evaluates variables that affect outcomes.
4. The program uses patient satisfaction data about program-specific characteristics for performance improvement activities.

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Standard 20.HCS.PI.4:
The program addresses sentinel events that occur and takes steps to prevent future occurrences.

Performance Requirements for 20.HCS.PI.4

• PI.4 -
1. The program has a process for preventing sentinel events. Note: Sentinel events are undesirable and usually unanticipated events that cause death or serious physical or psychological injury, or the risk thereof.
2. The program has a process for identifying and reporting sentinel events through established channels in the core setting and, as appropriate, to external agencies.
3. The program has a process for analyzing sentinel events if and when they occur.
4. The program conducts a thorough analysis of sentinel events.
5. The program documents its analysis of sentinel events.
6. The program implements changes based on its analysis of sentinel events.

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Comments

05 Oct 07 01:58 | BartWindrum said...:
Communication Algorthims
Providers ought to be required (trained and licensed) to engage in communication algorithms for all likely communication possibilities related to their practice. This to ensure no discontinuity of communication between providers and patient-families, because the downsides of communications failures, lapses, and absences are harmful -- especially during end of life events.

If providers cannot acquire the skills to develop and utilize communication algorithms and then engage in appropriate communication (evidenced by testing), they then should hire surrogates like full time ethicists to provide adequate patient-family communication in their stead.

© 2007 Bart Windrum [contact info in my profile]

29 Sep 07 02:31 | IamButDust said...:
Seven Principles of Patient Centered Care
7 Principles for the the Healthcare organization to have more quality communication with the patient by requiring less time in administrative and cross-functional systems for patient care:

1st Reduce fluff. 2nd Simplify. 3rd Merge like processes through organization.

4th Standardize steps 1-3. 5th Customize to specific needs. 6th Train & Maintain.

7th Supervise Change go back to step 1.

Use this sequence of steps to identify areas of risk assessment and mitigation. However realize that the macrosystem may limit or be adverse to the microsystem, so as each microsystem needs input channels to Performance Improvement for macrosystem changes.

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